Thursday, 2 February 2017

RESCUE THE INJURED FIRST !!! THE TALE OF APATHY & EMPATHY



From the Desk of Sagar Galwankar, MD, FACEE, Diplomat. ABEM (USA)

There is a lot of media discussion about the death of a Road Traffic Trauma Victim on the road without being helped by bystanders in Karnataka.

Additionally exactly a week ago this very media was abuzz covering the story of an Anesthetist who gave CPR to a patient at Mumbai airport and saved a life.

A Tale of two Cities, Same Scenarios where a patient needed help and two different actions.

One saved the life one did not.

This left me thinking about the challenges for bystanders to act as good Samaritans.

About the Road Traffic Incident:

With all International brands of cars on the modern Indian roads and the affordability quotient of masses on the high … car speed has become the major factor on buying car.
Unlike the other world…where car safety is criteria for car buying… in India design and speed are the major factors for car sales in India. 

There are 4 lanes to 6 lanes highways, there are international branded cars and there are our Indian drivers who have the least disregard for other drivers or pedestrians.  Coupled with that is the gross APATHY of the masses to just not respond to trauma victims lying on the roads.

I was traveling in India recently and in a city I saw a crash happen in front of my eyes. A driver was driving his imported car and it crashed into a motor cycle being driven by a Non Helmeted rider. It was an accident because the motor cycle skid and came in front of the car and the rider got head injury. The rider was awake and bleeding but what happened next ?

People gathered and started beating up the driver who had stopped, gotten out of the car and picked the rider and put him in his car and was taking him to the hospital. The first response of the by standers was the Driver in Car must have made the mistake …… Hammer the driver.

No one cared about the VICTIM ?

This is a wrong behavior which needs to be changed. The thought that Car Drivers have more money so they can afford cars and if they are in a crash it’s their fault so take justice into their hands and forget the patient is absolutely wrong. Forgetting the patient is just wrong.

This leads to the phenomenon of drivers running away after hitting other pedestrians / vehicles. If anyone wants to take the crash victims to the hospital they will not and just run away because they don’t want to face the mob mentality.

And the mob does nothing except to stare in majority of the cases. There are many cases when mobs do act….Well they should act always.

In many of my public events where I was called to inaugurate Road Safety and Basic Emergency Care Training programs I ask one question: What do you do when you see a crash on the road?

The truthful answer I get is: we don’t stop because we don’t want to get involved with the Mob or the Police. 

Why are we as citizens afraid of doing the right thing? 

Police will not bother you if you helped a bleeding victim. There is no use of learning Basic Life support courses if you don’t have the intent to help someone in need. We still are far from having EMS within minutes so the cars and bystanders are the first responders and hence going to a hospital which has 24/7 Emergency Care with Radiology and Laboratory Back up is the first important step after stabilizing the airway c spine and stopping the bleeding. 

Focusing on the Injured is very important and that’s a First.

We have crowded cities and vast rural corridors. 

We have lack of space for pedestrians to walk that’s why they walk on roads. 

We have high speed corridors going through rural area without crossings, overhead bridges or barricades. 

This is all there because development and infrastructure are in a mismatch. 

What we can match is our behavior. 


The government has constituted the good Samaritan act. Even though this has happened the myth that helping a trauma victim will invite undue involvement with the law continues to haunt the Indian bystander.

There are innumerable factors which are related to driving behaviors, road designs and traffic cultures. There are a multitude of factors related to legal crackdown upon road killers and the various agencies trying to institute safer roads and discipline violating drivers.

That is not in question here.

The question is “How do we change the GROSS INDIFFERENCE OF THE MASSES”

About the Mumbai CPR Saving Incident:

The CPR was provided by a trained anesthetist.
The media was abuzz.

The lesson learnt should have been

CPR Training at every level is a must. That is what media should have advocated.

AED across the nation is what should have been advocated.

Bystander RESCUE is crucial to saving lives for individual patients and in disasters.



SUGGESTED INTERVENTIONS:
EDUCATION, AWARENESS, ADVOCACY, SOCIAL MARKETING, PROMOTION
ENGAGING THE GOVERNMENT, THE AGENCIES, THE NON GOVERNMENTAL ORGANIZATIONS
TEACHING AT SCHOOL, COLLEGE, INDUSTRY LEVEL, USING RADIO, TV TO PROMOTE THE MESSAGE.

The vehicle industry and the road traffic license departments have to take a lead role in education and regulation of behavior of travelers. Just selling vehicles and issuing licenses is not the only responsibility. 

Changing our behavior and educating the masses is the key.


We should be responsible and always remember the INJURED IS ALWAYS FIRST !

INDUSEM has launched the Jan Suraksha Abhiyan on Injury Prevention which compliments the Prime Ministers Jan Suraksha Bima Yojana on Insurance of Accidents and Injured victim. www.indusem.org

Thursday, 5 January 2017

Decipher Dizziness aka “Giddiness”



From the Desk of Sagar Galwankar, MD



Today I want to discuss about another common complaint in Adult patients Emergency Departments often quoted as “Dizziness” aka “Giddiness” which is NON TRAUMATIC.

This is a very crucial complaint which requires a detailed history and clinical examination.

Vital Signs are very important and when I say Vital Signs I mean Temperature Pulse Blood Pressure and Respiration. Pulse Ox is also important.

I regularly ask for a Bedside Blood Sugar and Patient to be put on a Monitor and a IV Line be placed.

I will discuss some cases which brig out important aspects about this Major Masquerader.

Case One

55-Year-Old Healthy Male comes with Dizziness. Vital Signs Are Stable. Dizziness was sudden onset and patient felt diaphoretic. The patient is having Vertigo too and says everything is spinning.

There is Diabetes Hypertension History of CAD/MI or a CVA.

Pt looks distressed and feels everything is Spinning.

Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin and CXR and CT Head is ordered. 

Orthostatic BP is ordered and Pt is Orthostatic.

EKG Shows ST Elevation MI and Patient is sent to Cath lab.

Case Two

25-Year-old female comes with Dizziness. 

Patient is on her menses and feels very weak. 

She is restless and is saying that she can’t even stand. 

Bleeding started today. She is orthostatic positive.

Vitals , Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin Bedside UA and HCG Ordered.

HCG came back positive and Ultrasound was done. 

Patient had an ectopic and was sent to Sx.

Case Three

Patient comes with Fever Dizziness and inability to maintain balance. 55 Years old Male. Diabetes Hypertension + No H.O MI/CAD

Detailed Neuro exam reveals Ataxia. Dizziness started one hour ago.

Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin and CXR and CT Head is ordered which is negative.

Pt continues to feel dizzy.

MRI/MRA Brain is ordered and an Evolving CVA is diagnosed.

Pt  gets Thrombolysis.

Case Four

66 Year Old Female comes with Dizziness.

Says she has uneasiness in the chest and has bouts of dizziness.

When she feels dizzy she has Palpitations in the heart and she feels short of breath.

Pt is obese and has Diabetes Hypertension and is a Chronic Smoker with COPD.

Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin and CXR and CT Head is ordered which is negative.

Everything is negative and Pt again has Tachycardia upto 140 and feels dizzy in the ED.

A CTA Chest is ordered and she has Saddle Emboli in the Lung.


Case Five

15 Year old Downs syndrome Child comes with Mom complaining that “Room is spinning”

Clinical Exam is done. Neuro Exam is Normal.

ENT Exam reveals Fluid in Middle ear.

CT Head is done and patient has early Mastoiditis.

Treated with abx post admission.

Case Six

55 Year Old Female comes with Dizziness and vertigo. This has increased in last one week.

No history of weakness or chest pain or TIA or Anginal Symptoms

No Risk Factors

Vitals Orthostatic negative

Two sets of EKG Enzymes CT Head CBC LFT RFT Negative.

Clinical Exam normal

Epley Maneuver is done and patient feels better and is discharged after 4 hour observation.

Case Seven

35 Year Old male comes with extreme dizziness. Everything including clinical exam and Labs and CT Head is negative.

Cardiac Markers negative.

Detailed Deep History reveals that patient was at a rave party and a UDS reveals Amphetamines and Cocaine +

MRI/MRA Brain Reveals a Thalamic CVA

Case Eight
50 Year old Male comes with new onset dizziness. IV Oxygen Monitor and Labs EKG Ordered . No Risk Factors, But is Obese.

Inverted T waves seen in anterior leads.

Pt says that he has been having chest and abdominal discomfort.

Abdomen is tender all over.

Rectal Exam Positive for Fresh Blood.

Patient gets a Lactate Ordered which is high and so is the white count.

CTA Abdomen done which reveals SMA Ischemia.

Patient goes to Sx.

Summary

Dizziness is a great masquerader. Looks simple but can be a presentation of a life threatening Medical Conditions.

The Recipe to decipher Dizziness Evolves around a detail history keeping age and gender in mind.

Diabetes and Hypertension are risk factors for any Neuro Vascular or Cardiac Acute Syndrome. 

DKA and HTN Emergency are major causes of Dizziness and a IC Bleed needs to be ruled out.

Vital Signs Orthostatic and taking a detail history to R/O TIA / ACS is key
CBC LFT RFT Trop EKG CT Head and UA with Pregnancy Test (In Females in Pregnancy Age group w/o Hysterectomy) are basic labs.

When you do a clinical Exam do ask about H/O PE , Thyroid Issues, Pacemaker Status and H.O CA or MI

 Fever with dizziness could be early sign of meningitis / encephalitis/ brain abscess so do an LP and a CT Head

GI Bleed, Ectopic Pregnancy are also presentations which cannot be missed.

Arrhythmia could indicate cardiac ischemia or a conduction defect which may also be related to drug abuse or endocrinal disorders like thyroid storm.

A Drug abuse history is important and Pulmonary Embolism has many unconventional presentations.

Stress Anxiety are also diagnosis which can be present when all major causes are ruled out.

Abuse also should be considered.

Examining the ears and eyes and considering Ear Pathologies and Glaucoma can be a cause.

I will admit a patient if I suspect a TIA or ACS even though everything is negative. Ataxia is a Major factor which decides admission for me.

Admitting other conditions like GI Bleed Ectopic SMA Syndrome is a no brainer.

Dizziness can be an allied presentation of something very different, so remember that.

Ask for history of Trauma Syncope Fall Head Injury: The patient may not tell you that initially unless you ask.

When you have many patients in the ED with Different Presentations and one of them is Dizziness- Remember there is more to just being DIZZY !

Happy New Year to all !


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